- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $58,096.30
| Facility | | $15,631.57 | $15,631.57 | $58,096.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,631.57 / $15,631.57 / $16,608.54
| Professional | | $15,631.57 | $15,631.57 | $16,608.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,911.42 / $120,363.07 / $266,713.62
| Facility | | $5,911.42 | $120,363.07 | $266,713.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Facility | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,608.54 / $16,608.54 / $16,608.54
| Professional | | $16,608.54 | $16,608.54 | $16,608.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $13,252.88
| Professional | | $100.00 | $200.00 | $13,252.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $2,500.00
| Professional | | $30.00 | $30.00 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16,282.88 / $16,282.88 / $18,502.89
| Professional | | $16,282.88 | $16,282.88 | $18,502.89 |